APPENDIX A

FINANCIAL DECLARATION FORM

STATE OF INDIANA: CIRCUIT AND SUPERIOR COURTS OF
FAYETTE COUNTY
IN RE THE MARRIAGE OF: CAUSE NO.

Petitioner
And
Respondent Date:

FINANCIAL DECLARATION
OF

Husband* ____________________
Wife*-------------
Address Address

Soc Sec. No. Soc. Sec.

No.-----------------------------------
Badge/Payroll No. Badge/Payroll
No.------------------------------
Occupation Occupation
____________________
Employer Employer
_______________
Birth Date Birth Date

Date of Marriage:______________________________________________
Date of Physical Separation:
Date of Filing:_________________________

Names and dates of birth of all children of this relationship, whether by birth or adoption:
NOTE: THIS DECLARATION IS CONSIDERED MANDATORY DISCOVERY AND MUST BE
EXCHANGED BETWEEN PARTIES WITHIN THE TIME PRESCRIBED BY THE FAYETTE COUNTY
RULES OF FAMILY LAW. PARTIES NOT REPRESENTED BY COUNSEL ARE REQUIRED TO
COMPLY WITH THESE PRACTICES. FAILURE BY EITHER PARTY TO COMPLETE AND
EXCHANGE THIS FORM AS REQUIRED WILL AUTHORIZE THE COUT TO IMPOSE THE
SANCTIONS SET FORTH IN THE FAYETTE COUNTY RULES OF FAMILY LAW.

*In paternity actions, the term “husband” includes the putative father and the term “wife” includes the mother

13. TOTAL GROSS WEEKLY INCOME $_______________________ $

PART L INCOME AND EXPENSE STATEMENT

STATEMENT OF INCOME, EXPENSES, ASSETS AND LIABILITIES

Attach copies of state and Federal Income Tax Returns for last three taxable years and wage statement from
your employer for the last three (3) weeks.
NOTE: Attach separate sheets for subparts A, B and C for current spouse(s), roommate(s) or other(s) residing in
the home.
HUSBAND WIFE

A. GROSS WEEKLY INCOME from:

1. Salary and wages including commissions, bonuses,
allowances and overtime,
payable_____________ (pay period)
Note: If paid monthly, determine weekly
income by dividing monthly income by 4.3

2. Business/Self Employment Income before expenses

3. Commissions, Bonuses, Tips

4. Pensions and Retirement

5. Social Security

6. Disability, Unemployment, Worker's

Comp.

7. Public Assistance
(welfare, AFDC payments, etc.)

8. Food Stamps

9. Child support received for any child(ren) not born of the parties to this marriage
10. Dividends and interest

11. Rents/Royaltıes less ordınary & necessary expenses

12. All other sources (Specify)

B. ITEMIZED WEEKLY DEDUCTIONS HUSBAND WIFE

14.Weekly court ordered child support
for prior children
15.Weekly legal duty child support for
prior children
16.Weekly health insurance premiums
for
children of this case only
17.Weekly
alimony/support/maintenances
Paid to prior spouses (actual paid)
18.1/2 Weekly Self-employment Tax
_
_

19. Union dues

_
_

20. Weekly available income

(Line 13 less Lines 14-19)
_
21. Work Related Child Care
22.Extraordinary Health care Costs
23.Extraordinary Educational
Expenses

24. TOTAL GROSS WEEKLY DEDUCTIONS $ $

C. WEEKLY DISPOSABLE INCOME (Line 13 minus Line 24)

D. OTHER EXPENSES

State Incomes Taxes

Federal Income Taxes

Number of exemptions taken Husband: Wife:

Social Security

Medical Insurance - other then for children (list all persons covered):

Coverage available for children:

Medical ()
Dental ()
Eye Care ()
Psychiatric ()

Retirement or pension fund: Mandatory ( ) Øtional ( )

Child support withheld from pay (not including this case)

Garnishments (itemize on separate sheet)

Credit Union debts

Savings: Thrift plans ( ) Credit Union Savings ( ) Bonds ( ) Other (specify) ()

Other (Specify):

E. IN ALL CASES INVOLVING CHILD SUPPORT: Prepare and attach an Indiana Child Support
Guidelines Worksheet (with documentation verifying your income); or, supplement such a Worksheet within
ten (10) days of the exchange of this Form.

F. SELECTED MONTHLY LIVING EXPENSES: (Specify which party is the custodial parent and list
name and relationship of each member of the household whose expenses are included).

HUSBAND WIFE

Rent or mortgage payments (residence)

Real property taxes (residence) if not
included in mortgage payment

insurance (residence) if not included in

mortgage payment

Utilities (including water, sewer, electricity, Gas,

heat and garbage)

Telephone

Child Support not withheld from pay (not

including this case)

Medical (not covered by insurance) Dental

(not covered by insurance)

Insurance (life, health, accident, liability,

disability excluding payroll deducted and automobile)

School (including, if applicable, colleges,

universities or trade schools)

Child care and pre-school Transportation

(other than automobile) Auto payments

HUSBAND WIFE

Auto Insurance (not included in auto

payment) Other (Specify):
MONTHLY TOTAL EXPENSES

AVERAGE WEEKLY EXPENSES (Divide

total monthly expenses by 4.3)

Note: Indicate which of the foregoing expenses are delinquent and the amount thereof G. DEBTS AND
OBLIGATIONS: (Include credit union) Attach additional sheets as needed.

CREDITOR’S DATE BALANCE MONTHLY

NAME PAYABLE PAYMENT
TOTAL

ATTACH A COPY OF THE MOST RECENT STATEMENT FOR EACH DEBT.

Note: Indicate any special circumstances, i.e., premarital debts, debts in arrears on the date ofphysical
separation or date of filing and the amount or number of payments in arrears.

PART II. NET WORTH

List all property owned either individually or jointly. Indicate who holds or how title held: (H) Husband, (W)
Wife, or (J) Jointly. WHERE SPACE IS INSUFFICIENT FOR COMPLETE INFORMATION OR
LISTING PLEASE ATTACH SEPARATE SCHEDULE.

Ownership Value Balance(s) Owed

H/W/J_________________________ (Identify Creditors)

A. HOUSEHOLD FURNISHINGS (Value of furniture, appliances, and equipment, as a whole; that is, you
need not itemize)

B. VEHICLES
(Year and Make) Ownership Value Balance(s) Owed
Indicate regular driver H/W/J_________________________ (Identify Creditors)
B. SECURITIES (stocks, bonds, etc.)

Ownership Value Balance(s) Owed

Company H/W/J (Identify Creditors)

Attach documents from each plan verifying information. If not yet received, attach
a copy of your written requests to the plan(s).

D. CASH AND DEPOSIT ACCOUNTS (including banks; savings and loan associations; credit unions; thrift
plans; mutual funds; certifıcates of deposit; savings and checking accounts; IRA's and annuities)

Ownership___ Value Account No. Institution

H/W/J
E. LIFE INSØNCE

Company/ Ownership Beneficiary Face Type: Term, Cash Value/

Policy No. H/W/J Amount Whole Life Loan Amount Group
F. RETIREMENT PLANS

Name of Plan Ownership Vested Monthly Benefit Present Value

H/W/J Yes/No At Earliest (if known) Retirement
Date

G. REAL ESTATE (attach separate sheet with the following information for each parcel).

Address________________________ Type of Property

Date of acquisition

Original cost $_______________________ Present value $

Cost of additions $____________________ Basis for valuation (attach appraisal if

Obtained): Total costs $

Mtg. Balance $___________________

Other liens $_____________________
Equity $_________________________
Monthly payment $________________ To whom paid

Taxes (in not included m payment) $_ Insurance (if not included m payment) $___________________

Special Assessments_________________________________________________________________ Individual

contributions to real estate (for example, inheritance, pre-marital assets, personal loans)

H. BUSINESS OR PROFESSIONAL INTERESTS

(indicate name, share, type of business, value less indebteďness)

I. OTHER ASSETS (that is, specify coin, stamp or gun collections or other items of unusual value).
Use additional sheets as needed.

J. ATTACH ALL AVAILABLE DOCUMENTATION TO VERIFY VALUES.

PART III. ARREARAGE COMPUTATION

If there is alleged the existence of a support or other arrearage, attach all records or other exhibits regarding
payment history and compute the arrearage as of the date of filing of the petition or motion which raises that
issue.
PART IV. VERIFICATION

I declare, under the penalties of perjury, that the foregoing, including any valuations and attachments is true
and correct and that I have made a complete and absolute disclosure of all of my assets and liabilities.
Furthermore, I understand that if, in the future, it is proven to this court that I have intentionally failed to
disclose any asset or liability, I may lose the asset and may be required to pay the liability. Finally, I
acknowledge that sanctions may be imposed against me, including reasonable attorney's fees and expenses
incurred in the investigation, preparation and prosecution of any claim or action that proves my failure to
disclose assets or liabilities.

Date:
PARTY' S SIGNATURE

PART V. ATTORNEY'S CERTIFICATION

I have reviewed with my client the foregoing information, including any valuations and attachments, and sign
this certificate consistent with my obligation under Trial Rule 11 of the Indiana Rules of Procedure.

Date:
ATTORNEY' S SIGNATURE Name
Indiana Attorney Number:_____________________________ Address
Phone:
Fax: